1.
Using Cognitive Behavioral Therapy
to Improve Treatment Outcomes in
SUD Treatment
Developed and Presented by:
Roland Williams,
MA, LAADC, NCACII, CADCII, SAP
President and CEO, Free Life Enterprises
www.rolandwilliamsconsulting.com

2.
Class Introductions
• Who you are
• What you do
• What are your goals for today’s training
• How would you rate your clinical skills on a scale
of 1-10
• Your most memorable experience in your work
• Something about yourself you don’t normally tell
people
• One word that best describes you right now

3.
What is CBT?

4.
A Theory That Works
• If you change the way you think
• You can change the way you feel
• If you change the way you feel
• You will change the type of urges you have
• If your urges change
• Your actions will be change
• If your actions change
• Your consequences will change

5.
Cognitive Therapy Principles
• Thoughts lead to feelings
• Feelings lead to urges
• Urges lead to action
• Action leads to consequences

6.
T,F,U,A,C’s

7.
Listening To Your Head
• Our head can be a dangerous place, we often have
patterns of self defeating thoughts that lead us to
bad feelings and subsequently bad decisions.
Remember, thoughts lead to feelings, feelings lead to
urges and urges lead to actions, and actions have
consequences both good and bad.
• If we can learn to identify when a thought is
distorted, we can correct it or redirect in in such a
way that the chances of bad feelings and actions are
minimized.

8.
Internal Dialogue
My Stinking Thinking My sane thinking
My committee My conscience
My old tapes My recovery tools
My addict voice My Recovery self
My lower power My Higher Power
My rat brain My God brain
My dark side My light side
Mr. Hyde Dr. Jekyl
Negative self talk Positive self-talk
COGNITIVE DISTORTION RATIONAL RESPONSE

9.
Cognitive Distortions
• Overgeneralization
• Labeling
• Disqualifying the
positive
• Jumping to conclusions
• Emotional reasoning
• Mental filter
• Minimizing and
maximizing
• All or nothing thinking
• Personalizing
• Should statements

10.
• All-or-nothing thinking: You see things in black and
white categories. If your performance falls short of
perfect, you see yourself as a total failure.
• Overgeneralization: You see a single negative event
as a never-ending pattern of defeat.
• Mental filter: You pick out a single negative detail
and dwell on it exclusively so that your vision of all
reality becomes darkened, like the drop of ink that
discolors the entire beaker of water.

11.
• Magnification (catastrophizing) or minimization: You
exaggerate the importance of things (such as your
goof-up or someone else's achievement), or you
inappropriately shrink things until they appear tiny
(your own desirable qualities or the other fellow's
imperfections). This is also called the "binocular trick.”
• Emotional reasoning: You assume that your negative
emotions necessarily reflect the way things really are:
"I feel it, therefore it must be true.”
• Personalization: You see yourself as the cause of
some negative external event for which, in fact, you
were not primarily responsible.

12.
• Should statements: You try to motivate yourself with
shoulds and shouldn’t, as if you had to be whipped
and punished before you could be expected to do
anything. "Musts" and "oughts" are also offenders.
The emotional consequence is guilt. When you direct
should statements toward others, you feel anger,
frustration, and resentment.
• Labeling and mislabeling: This is an extreme form of
overgeneralization. Instead of describing your error,
you attach a negative label to yourself: "I'm a loser."
When someone else's behavior rubs you the wrong
way, you attach a negative label to him, "He's a damn
louse." Mislabeling involves describing an event with
language that is highly colored and emotionally
loaded.

13.
• Disqualifying the positive: You reject positive
experiences by insisting they "don't count" for some
reason or other. You maintain a negative belief that is
contradicted by your everyday experiences.
• Jumping to conclusions: You make a negative
interpretation even though there are no definite facts
that convincingly support your conclusion.
– Mind reading: You arbitrarily conclude that someone
is reacting negatively to you and don't bother to
check it out.
– The Fortune Teller Error: You anticipate that things
will turn out badly and feel convinced that your
prediction is an already-established fact.

14.
Triple Column Technique
Automatic Self Talk Cognitive Distortion Rational Response
He is an ass and a control
freak. He never liked me and
always tries to humiliate me.
I’m never going to finish this
program. I’m an addict and
will always be one. I’m going
to fail this program just like
the last.
The rest of the group thinks
I’m weak now.
I talk to much and will never
say another word.
I should just leave now, its
not going to get better.
Labeling and mislabeling
Emotional reasoning
All of nothing thinking
Mind reading
Fortune telling
Mind reading
Overgeneralization
Maximizing and
minimizing
Disqualifying the positive
Should statement
Fortune telling
He’s been cool with me
and is just doing his job.
This is the first time I ever
felt humiliated by him.
Maybe this is my stuff.
If I hang in there I know I
can finish. This program is
nothing like the last one,
and I’m not the same guy I
was then.
Actually many group
members said I handled it
well. I was trying to help
and will not give up. I know
I can make it better.
Offending incident: Counselor confronted me in group when I offered advice

15.
CBT and Group Therapy

16.
Group Dynamics
• Beginning
– Practice opening exercises
• Middle
– How to use the time
• End
– Closure exercise

17.
Johari Window
Open to you and others Open to you
Open to others Closed to you and others

18.
AA compared to Therapy Group
• Abstinence
• The how of Recovery
• Opening Rituals
• Sharing story
• No cross-talk
• Focus on 12 Steps
• No leaders
• Don’t take inventories
• Focus on own issues
• T. F.U.A’s
• The why of Recovery
• Opening Rituals
• Self disclosure
• Encourage cross-talk
• Focus on process
• Facilitated
• Give direct feedback
• Willing to confront others

19.
Benefits of Group Therapy
• Group counseling is often more effective than the
individual approach because:
• Group members can practice new skills needed every
day.
• There is the benefit of feedback and insight of other
members.
• The group can model real life relationships.
• Members can learn how to cope with problems by
observing others.
• Practical advantages, such as costs and time economy.
• Ideally use a combination of group and individual
therapy.

20.
Types of Groups

21.
Problem-Solving Process Group
• Process group is the group in which clients build their
communication and problem solving skills. There is no pre-
determined topic. Facilitators guide the group to help them:
• Understand their problem more clearly;
• Learn the steps of problem solving in a safe, supportive,
respectful environment;
• Identify and change: mistaken thinking, unmanageable
feelings, urges to do things that make life more painful, self-
defeating behaviors and relationships that make problems
worse;
• Be listened to, taken seriously, respected and affirmed;
• Tap into the group conscience, a powerful source of
knowledge, courage, strength and hope in personal problem
solving.

22.
Focused Work Group
• These are topic-driven workgroups.
• Core assignments are addressed here such as:
Recovery Plans (treatment goals), First Step
presentations and Exit Plans.
• Individualized assignments may also be presented.
• Other topics are diverse and reflect the needs of the
current population as well as the specific talents of
the facilitator (e.g., communication skills, grief and
loss).
• These groups are highly interactive, stressing peer
feedback.

23.
Psycho-Education Group
Educational groups or lectures are didactic and
participative. Core topics may include:
• The disease of addiction
• Medical aspects,
• Relapse dynamics,
• Introduction to the 12 steps
• Anger management, and
• Practical application of recovery principles.

24.
Tips for the Facilitator
The group is the client
You don’t have to be right
Avoid Dyads
Use the Group
If you’re doing most of the talking,
something’s wrong
Don’t pontificate
Be careful with self-disclosure
Don’t participate in exercises
Get the group grounded, centered
Watch for non-verbal communication
Let silence be okay
Comfort is not the goal
Let people cry, vent, and/or be angry
Be on time
Make eye contact
Use I statements
Don’t open something you can’t
close by end of the group
Trust you instincts
Don’t portray your opinions as facts
Don’t be a bully
Avoid leading questions
Never sit next to a co-facilitator
Don’t allow spectators in the group,
make them participate
Bring everyone into the discussion
Resist the urge to ‘fix-it’
Don’t play favorites
Don’t allow scapegoats

25.
Tips for the Facilitator, cont.
Convince the group the power is in the
group, not the facilitator
Don’t manipulate the group to take
your side
Don’t punish group members for
confronting, challenging, or
disagreeing with you
Don’t take responsibility for group
member recovery
Confront inappropriate behavior as it
occurs
Insist that group members talk directly
to each other, not about each other
Respect group member’s
boundaries
Ask one question at a time
Pay attention to group members
stress level
Pay attention to your stress level
Teach the group how to confront
each other, don’t be the only
one who does it
Pay attention to when people need
to leave the group
Explain the group process to each
new member before they begin

26.
Client Specific Issues

27.
Challenging Clients
• The Dominator
• The Hider
• The Bully
• The Know-it-all
• The Junior Therapist
• The Super-Grouper
• The Cry-Baby
• The Rescuer
• The Outlaw

28.
Coping Mechanisms
• Acting out: not coping - giving in to the pressure to misbehave.
• Aim inhibition: lowering sights to what seems more achievable.
• Attack: trying to beat down that which is threatening you.
• Avoidance: mentally or physically avoiding something that causes distress.
• Compartmentalization: separating conflicting thoughts into separated compartments.
• Compensation: making up for a weakness in one area by gain strength in another.
• Conversion: subconscious conversion of stress into physical symptoms.
• Denial: refusing to acknowledge that an event has occurred.
• Displacement: shifting of intended action to a safer target.
• Dissociation: separating oneself from parts of your life.
• Fantasy: escaping reality into a world of possibility.
• Idealization: playing up the good points and ignoring limitations of things desired.
• Identification: copying others to take on their characteristics.

29.
Coping Mechanisms, cont.
• Intellectualization: avoiding emotion by focusing on facts and logic.
• Introjection: bringing things from the outer world into the inner world.
• Passive aggression: avoiding refusal by passive avoidance.
• Projection: seeing your own unwanted feelings in other people.
• Rationalization: creating logical reasons for bad behavior.
• Reaction Formation: avoiding something by taking a polar opposite position.
• Regression: returning to a child state to avoid problems.
• Repression: subconsciously hiding uncomfortable thoughts.
• Somatization: psychological problems turned into physical symptoms.
• Sublimation: channeling psychic energy into acceptable activities.
• Suppression: consciously holding back unwanted urges.
• Symbolization: turning unwanted thoughts into metaphoric symbols.
• Trivializing: making small what is really something big.
• Undoing: actions that psychologically 'undo' wrongdoings for the wrongdoer.

30.
Stages of Change
• Pre-Contemplation
• Contemplation
• Preparation
• Action
• Maintenance

31.
Developmental Model of Addiction
• Experimentation: Social use, I can take if or leave it, I
have no problems
• Situational misuse: Drugs and alcohol make me a
better man in certain situations
• Problem use: I use to cope with everyday life issues,
and I’m having problems
• Dependence: I continue to use despite known
negative consequences, loss of control, blackouts,
tolerance and withdrawal, lots of problems

32.
Developmental Model of Recovery
• Transitional: I have a problem but I can control it.
• Stabilization: l can’t control d/a and I need to learn
how to not use
• Early recovery: Change playmates, playgrounds and
playthings
• Middle recovery: Balance
• Late recovery: Deal with unresolved childhood issues
• Maintenance: Continue to nurture bio-psycho-social
and spiritual growth

33.
Utilizing Cognitive Therapy Techniques
in Group

34.
Cultural Considerations

35.
Improving Communication Across Cultural Boundaries
• Recognize differences
• Build Your Self-Awareness
• Active listen, then interpret
• Don’t assume your interpretation is correct
• Verbalize your own non-verbal signs
• Share your experience honestly
• Acknowledge any discomfort, hesitation, or concern
• Practice politically correct communication
• Give your time and attention when communicating
• Don’t evaluate or judge

36.
Cultural Adaptation Styles
Integration Model
Dominant Minority
X
X
X X

37.
Recovery Grid
Biological Psychological
Social Spiritual
19 15
22 14

38.
Bio-Psycho-Social-Spiritual: Cultural Challenges
• Biological:
– lack of access to medical care
– distrust of medical providers
– cultural healing practices
– culturally related illnesses
– culturally related diet considerations

39.
Bio-Psycho-Social-Spiritual: Cultural Challenges
• Psychological
– low self esteem
– feelings of inadequacy
– pessimism
– suspicion and distrust
– depression
– reluctance to seek therapy
– feeling different or excluded

40.
Bio-Psycho-Social-Spiritual: Cultural
Challenges
• Social
– high risk living situations
– drug infested neighborhoods
– marketing strategies targeting minorities
– friends don’t always support positive change
– family beliefs about using/ seeking help
– community/extended family support

41.
Bio-Psycho-Social-Spiritual: Cultural Challenges
• Spiritual
– Spiritual values in conflict: shame/guilt
– church support systems
– AA conflicts with religious beliefs
– Spiritual rituals that involve use of drugs or
alcohol

42.
Bio-Psycho-Social-Spiritual Cultural:
Cultural Challenge
• Give to your community
• Spend time with your
children
• Talk up not down to
your people
• Patronize your peoples
business
• Subscribe to your
cultures publications
• Give to culturally
friendly charities
• Study your history
• Teach your history
• Be a positive role model

43.
Closure Exercise
• Who or what stood out for you most today,
explain your answer to the group
• What if anything are you going to do different
in your work.